MEDICARE: GREGORY ALLEN LARSON FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	2973	MN
2	363LF0000X	Family Nurse Practitioner	AP2705	AZ

General Provider Information

NPI Number	:	1578536892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY ALLEN LARSON FNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 617
Second Line	:
City	:	SOMERTON
State	:	AZ
Zip	:	85350-0617
Country	:	US
Telephone Number	:	928-236-8001
Fax Number	:	928-722-6113

Provider Business Practice Location Address
First Line	:	1233 N MAIN ST
Second Line	:	STE 1A
City	:	SAN LUIS
State	:	AZ
Zip	:	85349
Country	:	US
Telephone Number	:	928-550-5514
Fax Number	:	928-722-6113

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	04/01/2019

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